Emergency medicine: How a child looks helps in diagnosis, treatment

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Sunday July 29, 2012 9:28 AM

How does the kid look?

It’s the first question out of any emergency physician’s mouth when inquiring about a child. In
my world, asking whether a child looks good is intended to learn whether the child is sick or
gravely injured.

This is a description that takes into account an array of assessments, including whether the
airway is open and the nervous system is functioning. When I hear that a baby looks great and is
cooing, smiling and playing with Mom, I can let out a sigh of relief and breathe again.

But when my senior resident recently told me that a baby, Sarah, did not look well, we went into
full alert. Sarah was almost 1 year old and had been found in her portable crib drooling and
listless. Mom immediately knew something was wrong.When Sarah was brought into the major
resuscitation room, she was limp and dusky blue and had a weak cough. We all could hear a
high-pitched squeak when she breathed, more so when she inhaled than exhaled. One of the residents
began to ask mom all the salient historical questions.
How old is Sarah? How much does she weigh? Did this happen suddenly, or had she been sick? When did she first
notice the baby wasn’t well? Was she born full-term? Any complications with the delivery? Are there
siblings at home? Is she up-to-date on her immunizations?

I could appreciate the train of thought — we need metrics on weight and age for drug
dosing.Could this be an infection? Gradual onset, under-

immunized child, or sickly since birth? Or was there a mischievous 3-year-old sibling feeding
our patient pennies, carrots or Legos at home?

The nurse started oxygen, which helped tremendously. Sarah began to cry, look around the room
and pull at the face mask.The high-pitched squeak was still there, and we could tell there was
something in her upper airway that was causing the squeak and the drooling. Was the cause of this
constriction something that belonged there but had swollen? Or was it something that didn’t belong
there, such as food, a toy or a battery?If it was swelling, stressing her more by starting an IV
could make things worse. But doing nothing wasn’t an option.Then she coughed. A big squeaky, wheezy
inhale and a forcible cough. We were hopeful that the Lego/carrot/penny would fly across the room.
Nothing.Sarah’s next breath in was clear. She cried a few more times and reached for Mom’s arms. We
realized we were out of the fire but also knew that whatever caused her gravely ill appearance was
unlikely to have vanished.A chest X-ray confirmed the problem about five minutes later. One side of
her lung had expanded and was filled to its fullest extent, and the “normal” side, by comparison,
looked rather dense. The overinflated side was that way because air couldn’t escape. It was blocked
by whatever had been sucked down from her upper airway into her bronchus. Still, the X-ray didn’t
reveal anything so obvious as a penny or battery, but whatever it was had a ball-and-valve effect
on the air in the lung.

Sarah was transferred to Nationwide Children’s Hospital, and a bronchoscope revealed the trouble
— a small wooden bead.Fortunately, my little patient had self-treated, in a sense, turning a
life-threatening upper-airway obstruction into something urgent but not deadly. With one good
cough.